Provider Demographics
NPI:1164629283
Name:GODFREY, BRACKEN ROBERT (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:BRACKEN
Middle Name:ROBERT
Last Name:GODFREY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 561 BOX 781
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-0008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 CLARK WAY
Practice Address - Street 2:
Practice Address - City:SOMERSWORTH
Practice Address - State:NH
Practice Address - Zip Code:03878-4403
Practice Address - Country:US
Practice Address - Phone:603-692-2045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4082122300000X
NH44791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist